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Dermoscopy of Pigmented Basal Cell Carcinoma
Pigmented basal cell carcinoma refers to a subtype of basal cell carcinoma characterized by the presence of significant amounts of melanin within the tumor and in the surrounding stromal melanophages. It is an uncommon variant of BCC, with a lower incidence rate and usually presents as pigmentation at the site of lesion. PBCC may present…
Dermoscopy of Pigmented Basal Cell Carcinoma (BCC) | IBOOLO
Learn to identify pigmented basal cell carcinoma (BCC) with dermoscopy of bcc. This guide explains key features like arborising telangiectasias and ovoid nests, IBOOLO helping you make a more accurate diagnosis.
Dermoscopy of BCC: A Visual Guide to Pigmented Basal Cell Carcinoma
Basal cell carcinoma (BCC) is the most common form of skin cancer, and a significant portion of these are pigmented. A confident diagnosis requires a keen eye and the right tools. Dermoscopy of BCC is the gold standard for revealing the hidden features of these lesions. This guide will walk you through the definitive dermoscopic patterns of pigmented BCC dermoscopy, helping you confidently distinguish it from other skin conditions and ensure early, effective treatment.
Recognizing the Key Dermoscopic Features of Pigmented BCC
Unlike a benign mole or melanoma, pigmented BCC has a specific set of visual cues under a dermatoscope. These features often appear together, providing a clear roadmap to diagnosis. Look for these signs in any suspicious pigmented lesion:
1. The Arborizing Telangiectasias
This is arguably the most specific sign of BCC. These are thin, branching blood vessels that look like the limbs of a tree. They are typically found on the surface or periphery of the lesion and are best visualized with polarized dermoscopy, which reduces surface glare.
[Image: Insert a high-quality dermoscopic image of a pigmented BCC showing clear arborizing telangiectasias.]
2. The "Rolled Border" or Nodular Appearance
Pigmented BCC often presents with a raised, "rolled" border. Under dermoscopy, this can appear as a translucent or pearly nodule. The internal structures of the lesion may be obscured by this nodular pattern, but the presence of arborizing vessels is a major clue.
[Image: Insert a high-quality dermoscopic image of a pigmented BCC showing a raised nodule with a rolled border.]
3. The Pigment Clues: Ovoid Nests and Ulceration
The pigmentation in BCC is often disorganized and can appear in various forms. Common features include:
- Ovoid Nests: These are well-defined, dark brown or bluish-gray ovoid (egg-shaped) structures that lack a clear network.
- Ulceration: The lesion may show a central ulcer, sometimes with a crust or bleeding.
- Blotches and Dots: The pigmentation can be in the form of irregular blotches and small dots that are not arranged in a uniform pattern.
[Image: Insert a high-quality dermoscopic image of a pigmented BCC showing ovoid nests and blotches.]
Differentiating Pigmented BCC from Melanoma and Benign Lesions
One of the most critical applications of dermoscopy of BCC is its ability to differentiate it from other common skin conditions, particularly melanoma. While some features can overlap, there are key differences:
- BCC vs. Melanoma: Melanoma often shows asymmetry, an irregular pigment network, and a variety of colors (black, brown, white, blue). While both can have ulceration, melanoma rarely has the classic arborizing vessels of BCC.
- BCC vs. Seborrheic Keratosis: A seborrheic keratosis, a benign lesion, typically has milia-like cysts (small, white or yellow dots) and comedo-like openings (dark, pore-like structures). It lacks the arborizing vessels and ovoid nests of BCC.
Enhancing Your Diagnosis: Practical Tips for Pigmented BCC Dermoscopy
Achieving a precise diagnosis goes beyond just recognizing patterns. Here are some tips for a comprehensive evaluation:
- Use Polarized Light: When evaluating a potentially pigmented BCC, always switch to polarized light. This will minimize surface glare and make the arborizing vessels more prominent.
- Scan Systematically: Move your dermoscope slowly across the entire lesion. Some key features, like arborizing vessels, may only be present in a small area.
- Take Digital Images: For suspicious lesions, capture high-quality digital images. This allows for long-term monitoring and can show subtle changes over time that might indicate malignancy.
The Power of Dermoscopy in Clinical Practice
The ability to confidently diagnose pigmented BCC with dermoscopy is a game-changer in dermatology. By mastering the recognition of key features like arborizing telangiectasias, ovoid nests, and ulceration, clinicians can make rapid, non-invasive diagnoses. This not only leads to earlier and more effective treatment for patients but also helps to avoid unnecessary biopsies of benign lesions. Dermoscopy of BCC is a fundamental skill that empowers dermatologists and improves the standard of patient care.
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Pigmented basal cell carcinoma refers to a subtype of basal cell carcinoma characterized by the presence of significant amounts of melanin within the tumor and in the surrounding stromal melanophages. It is an uncommon variant of BCC, with a lower incidence rate and usually presents as pigmentation at the site of lesion. PBCC may present initially as only mild pigmentour alterations and slight skin changes, which could possibly remain unrecognizable. Because dermoscopy is extremely sensitive, it can find these subtle changes and thus allows to detect this earlier.
What is pigmented basal cell carcinoma?
Epidemiologically, pigmented basal cell carcinoma occurs more frequently with increasing age. In addition, risk factors involved in the PBCC pathogenesis include chronic malady of sun exposer (sunbathing), presence of ultraviolet radiation and ionizing Radiation, Chemical contamination; outside stimuli are included with genetic factor. PBCC is the most challenging because early diagnosis and treatment are critical. Although the disease had a low-grade malignant potential, untreated PBCC could cause much harm to its carrier.
The most distinct difference between pigmented basal cell carcinoma and other forms of basal cellular carcinomas (such as nodular ulcerative type, superficial type) is the prominent hyperpigmentation of the lesions in contrast to those that show mostly different colors rather than black. Compared with non-pigmented basal cell carcinoma, the incidence of pigmented BCC is low.
Advantages of dermoscopy in the diagnosis of pigmented skin lesions
The basic principle of dermoscopy is the use of optical magnification to avoid reflected light from then surface and provide enlargement on fine structures at the skin surface, allowing a deeper look further beyond stratum corneum or even in superficial dermis. Dermoscopy should be done under the supervision of a dermatologist. The skin in the lesion area should be relatively dry before examination, and lubricants or ointments are not applied.
This technique visualizes skin structures that are not easily observed by the naked eye, including a detailed dermatoscopic view of pigment networks and vascular patterns among other important diagnostic landmarks to aid in early diagnosis from melanomas and pigmented basal cell carcinoma. Moreover, dermoscopy is a non-destructive and elegant process that involves no pain or harm to the patient. Dermoscopy is a simple, quick and inexpensive method as compared to other screening methods.
Dermoscopic features of pigmented basal cell carcinoma
Blue-gray globules: dermoscope might sometimes show large, round or oval structures which appear to be filled with melanin reflected as bluish-grey.
Dendritic blood vessels: a dermoscopic hallmark of basal cell carcinoma, also seen in pigmented BCC. This pattern is dendritic and originates from a central point, making it very distinctive.
Pigmentation network: PBCC often shows a lack of a typical pigmentation network; instead, it may appear as an unstructured or foliated area around the lesion.
Differences between pigmented basal cell carcinoma and other pigmented skin lesions
Dermoscopy allows the visualization of features crucial to distinguishing PBCC from other pigmented lesions
(1). Melanoma.
Appearance: The lesion is asymmetrical with irregular borders and many colors (brown, black, blue, red ).
Dermoscopy: Atypical pigmentation network, irregular streaking with blue-white veil.
Difference: PBCC typically shows blue-gray blobs, dendritic vessels surrounding usual pigment network
(2). Blue nevus.
Appearance: A unique lesion that is blue or black
Dermoscopy: Uniform blue pigmentation without any structure
Distinction: PBCC has additional features such as dendritic vessels and blue-gray ovoid nests
(3). Solar Lentigo.
Appearance：Brown macules that are flat and often found in sun-exposed sites
Dermoscopy: A fine mesh pattern of uniform pigmentation.
Difference: PBCC demonstrates a more complex arrangement of blue-gray globules and dendritic blood vessels
Interpretation difficulties and common pitfalls in dermoscopic images of pigmented basal cell carcinoma
The resultant dermoscopic image of PBCC generally shows a complex structure with various types of blue-grey blobs and dendritic blood vessels, which demand very-rich experience as well as expertise in the identification and interpretation process. Moreover, dermoscopic features of PBCC may resemble some benign lesions like blue nevi and pigmented nevus which should be accurately differentiated in reading.
During interpretation of dermoscopic images, some doctors may focus too much on a single criterion (e.g., blue-gray blobs) and ignore other clinical data or notable features observed through polarisation analysis. Moreover, pigmented basal cell carcinoma also presents as a black papule or nodule and its dermoscopic image resembles that of melanoma. Consequently, sometimes a biopsy is done to differentiate pigmented basal cell carcinoma from melanoma.
A clinical case of pigmented basal cell carcinoma
Case Presentation
Patient: 65-year-old male with a long history of sun exposure and pigmented lesion on left cheek. It has been slowly growing larger for the last 12 months.
Examination: 1.5 cm ill-defined dark plaque with a sclerotic surface
Dermoscopic examination:
(1) A bluish or grayhill to brown net is observed which has a different color and intensity in the various areas of the plaque.
(2) Multiple blue-gray spherules irregularly arranged and surrounded by normal skin
(3) Maple-like appearance at edges of the plaque with tiny dendritic blood vessels distributed in marginal areas.
Diagnostic process:
Preliminary Diagnosis: Clinical and dermatoscopic features were consistent with the diagnosis of pigmented basal cell carcinoma.
Further Examination: A biopsy from the margin of plaque was obtained under local anesthesia.
Histopathological Results: Pathological sections showed the presence of a tumor mass in the dermis composed of basal-like cells. Melanocytes were seen in the tumor parenchyma and melanophagocytes were seen in the interstitium, consistent with pigmented basal cell carcinoma.
Diagnosis:
He was eventually diagnosed with pigmented basal cell carcinoma.
Association between dermoscopic and histologic features
Pigmented lesions: Dermoscopic features of pigmented lesions often reflect the proliferation, distribution and arrangement of melanocytes within the lesion, as well as the morphology and density of blood vessels.
Non-pigmented lesions: The dermoscopic features of non-pigmented lesions are often associated with changes in cellular components such as keratinocytes and fibroblasts within the lesion.
Vascular structure: Dermoscopic features of vascular structure are often consistent with histopathologic changes in vascular morphology and density. For example, in inflammatory dermatoses, the dermoscopic vascular structure may exhibit features such as dilatation and congestion, which are consistent with a histopathologic vascular inflammatory response.
